VA HEALTH CARE

Improvements Needed 

in Processes Used to 

Address Providers’

Actions That 

Contribute to Adverse 

Events

Report to Congressional Requesters

December 2013

GAO-14-55

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-14-55, a report to 

congressional requesters

December 2013

VA HEALTH CARE

Improvements Needed in Processes Used to Address 

Providers’ Actions That Contribute to Adverse 

Events

Why GAO Did This Study

Adverse events—clinical incidents that 

may pose the risk of injury to a patient 

as the result of a medical intervention, 

rather than the patient’s underlying 

health condition—can occur in all 

health care delivery settings. VAMCs 

can use one or more of the protected 

(confidential and nonpunitive) and 

nonprotected processes to evaluate 

the role of individual providers in 

adverse events. GAO was asked to 

review the extent to which processes 

used to respond to adverse events are 

carried out across VAMCs. In this 

report, GAO examined (1) VAMCs’ 

adherence to VHA’s protected peer 

review process, and the extent to 

which VHA monitors this process, and 

(2) VAMCs’ adherence to VHA’s 

nonprotected processes and the extent 

to which VHA monitors these 

processes. To conduct this work, GAO 

visited four VAMCs selected for 

variation in size, complexity of 

surgeries typically performed, and 

location. GAO reviewed VHA policies 

and federal internal control standards 

and analyzed data from the four 

selected VAMCs. GAO also 

interviewed VHA and VA OIG officials, 

as well as officials from VISNs of the 

four selected VAMCs.

What GAO Recommends

GAO recommends that VA take action 

to ensure VAMCs adhere to certain 

elements of the peer review policy, 

require VAMCs to report data on 

implementation of peer review triggers, 

and develop more specific policy to 

help guide the FPPE process, 

including documentation requirements.

In its written comments, VA generally 

concurred with GAO’s conclusions and 

recommendations.

What GAO Found

The Department of Veterans Affairs (VA) medical centers GAO visited did not 

adhere to certain policy elements of the protected peer review process, and 

monitoring by VA’s Veterans Health Administration (VHA) is limited. According to 

policy issued by VHA, protected peer review may be used by VA medical centers 

(VAMC) when there is a need to determine whether a provider’s actions 

associated with an adverse event were clinically appropriate—that is, whether 

another provider with similar expertise would have taken similar action. Despite 

VAMC officials’ general understanding of the protected peer review process, 

none of the VAMCs GAO visited adhered to all four protected peer review policy 

elements selected for review, including the timely completion of reviews, and the 

timely development of peer review triggers that signal the need for further review

of a provider’s care. Failure of VAMCs to adhere to the protected peer review 

policy elements may result in missed opportunities to identify providers who pose 

a risk to patient safety. Veterans Integrated Service Networks (VISN), 

responsible for oversight of VAMCs, monitor VAMCs’ protected peer review 

processes through quarterly data submissions and annual site visits. A VHA 

official said that VHA monitors the process by reviewing and analyzing the 

aggregated quarterly data submitted by VAMCs through the VISNs. The VA 

Office of the Inspector General (OIG) also conducts oversight of the protected 

peer review process as part of a larger review of VAMCs’ operations. While the 

VISNs and VA OIG have reviewed VAMCs establishment of peer review triggers 

to prompt further review of a provider‘s care, neither they nor VHA has monitored 

their implementation. As such, VHA cannot provide reasonable assurance that 

VAMCs are using the peer review triggers as intended, as a risk assessment 

tool. This weakens VAMCs’ ability to ensure they are identifying providers that 

are unable to deliver safe, quality patient care. 

VAMCs’ adherence to the nonprotected focused professional practice evaluation 

(FPPE) process is unclear due to gaps in VHA’s policy on documentation 

requirements, and VHA does not routinely monitor nonprotected processes. An 

FPPE for cause is a time-limited evaluation during which the VAMC assesses the 

provider’s professional competence when a question arises regarding the 

provider’s ability to provide safe, quality patient care. Information collected 

through the FPPE can be used to inform adverse actions, such as limiting the 

provider’s scope of care. Although VAMC officials were generally aware of the 

FPPE process, there are gaps in VHA’s policy regarding how these evaluations 

should be documented and what information should be included, which limited 

GAO’s ability to assess VAMCs’ adherence to the process. For example, one 

VAMC provided GAO with documentation labeled as an FPPE and identified by 

the service chief as an FPPE; however, the quality manager said a formal FPPE 

was not conducted and that the documentation was actually part of a protected 

peer review. These differing views illustrate that, even within the same facility, 

gaps in VHA’s policy on documenting FPPEs create a lack of clarity and 

opportunities for misinterpretation and inappropriate use. Moreover, the gaps in 

VHA’s policy may hinder VAMCs’ ability to appropriately document the evaluation 

of a provider’s skills, support any actions initiated, and track provider-specific 

incidents over time. There is no routine monitoring of FPPEs for cause by VHA, 

VISNs, or VA OIG.

View GAO-14-55. For more information, 

contact Debra Draper at (202) 512-7114 or 

draperd@gao.gov.
Page i GAO-14-55 VA Adverse Events

Letter 1 

Background 8

VAMCs Did Not Adhere to Certain Policy Elements of the 

Protected Peer Review Process, and Monitoring by VHA Is 

Limited 15

VAMC’s Adherence to the FPPE Process Is Unclear Due to Gaps in 

Policy Addressing Documentation Requirements; VHA Does Not 

Routinely Monitor Nonprotected Processes 26

Conclusions 31

Recommendations for Executive Action 32

Agency Comments and Our Evaluation 33

Appendix I Example of a VA Medical Center’s (VAMC) Focused 

Professional Practice Evaluation (FPPE) Template 36

Appendix II Comments from the Department of Veterans Affairs 40

Appendix III GAO Contact and Staff Acknowledgments 45

Tables

Table 1: VA Site Visit Locations and Characteristics 5

Table 2: Adherence to Selected Protected Peer Review Policy 

Elements at Four VA Medical Centers (VAMC) GAO 

Visited, Fiscal Years 2009 through 2011 16

Table 3: Date Established and Description of Peer Review Triggers 

at Four VA Medical Centers (VAMC) GAO Visited 18

Table 4: Protected Peer Review Process Monitoring Activities by 

Selected VA and Veterans Health Administration (VHA) 

Organizational Components 23

Figures

Figure 1: Example of Decision Process Used by VA Medical Center 

(VAMC) Officials When Responding to an Adverse Event 9

Contents 
Page ii GAO-14-55 VA Adverse Events

Figure 2: VA and Veterans Health Administration (VHA) 

Organizational Components Involved in Monitoring VA 

Medical Centers’ (VAMC) Adverse Events and Related 

Processes 14

Abbreviations

ADUSH Assistant Deputy Under Secretary for Health

AIB administrative investigation board

DUSHOM Deputy Under Secretary for Health for Operations 

 and Management

FPPE focused professional practice evaluation

OIG Office of Inspector General

VA Department of Veterans Affairs

VAMC VA medical center

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

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Page 1 GAO-14-55 VA Adverse Events

441 G St. N.W.

Washington, DC 20548

December 3, 2013

The Honorable Patty Murray

Chairman

Committee on the Budget

United States Senate

The Honorable Bernard Sanders

Chairman

Committee on Veterans’ Affairs

United States Senate

The Honorable Michael Michaud

Ranking Member

Committee on Veterans’ Affairs

House of Representatives

The Honorable Eddie Bernice Johnson

House of Representatives

The Department of Veterans Affairs’ (VA) Veterans Health Administration 

(VHA) operates one of the largest health care delivery systems in the 

United States. VHA’s health care system includes 152 VA medical 

centers (VAMC) that offer a variety of inpatient and outpatient services, 

ranging from routine examinations to complex surgical procedures. 

According to VHA officials, these services are provided by a variety of 

health care professionals, including over 39,000 physicians and dentists. 

As in all health care delivery settings like VAMCs, adverse events—

clinical incidents that may pose the risk of injury to a patient as the result 

of a medical intervention or the lack of an appropriate intervention, such 

as a missed or delayed diagnosis, rather than that patient’s underlying 

medical condition—may occur, resulting in potential or actual harm to 

patients.1

 

1

Adverse events may not always be attributable to an error made by a provider; for 

example a patient fall occurring while under medical care may be considered an adverse 

event, but be unrelated to patient care.

In an analysis of VHA data published in 2011, for example, 

researchers found that there were 101 reported surgical adverse 

events—events pertaining to incorrect surgical procedures, such as a 

 
 

Page 2 GAO-14-55 VA Adverse Events

procedure performed on the wrong patient or with the wrong implant—

across VAMCs from mid-2006 to 2009.2

VHA requires that VAMCs take appropriate action to report and evaluate 

adverse events.3 VHA generally gives VAMCs discretion in choosing 

which process to use in responding to reported adverse events. VAMCs 

generally use one or more of the following three processes to evaluate 

the role of individual providers in adverse events: peer review for quality 

management, focused professional practice evaluation (FPPE), and 

administrative investigation board (AIB).4 Peer review for quality 

management is used when there is a need to determine whether a 

provider’s actions associated with an adverse event were clinically 

appropriate—that is, whether another provider with similar expertise 

would have taken similar action. An FPPE is a process whereby the 

VAMC evaluates a provider’s competence in a specific area of clinical 

expertise, such as a surgical procedure, when a question arises regarding 

the provider’s ability to provide safe, quality patient care.5

 

2

Julia Neily et al., “Incorrect Surgical Procedures within and Outside of the Operating 

Room, A Follow-up Report,” Archives of Surgery, vol. 146, no. 11 (2011).

An AIB can be 

used to investigate whether an adverse event was the result of a 

3

According to VHA officials, VHA requires adverse events to be reported to appropriate 

VAMC officials through each VAMC’s incident reporting system, or through other methods 

such as a phone call or email to the applicable medical center’s patient safety manager or 

risk manager. In addition to identifying and reporting adverse events, VAMCs have a 

quality management program that enables them to identify and respond to other quality-ofcare issues that may not rise to the level of an adverse event. VHA uses the terms quality 

management, quality improvement, and quality assurance interchangeably.

4

See GAO, Veterans Health Care: Veterans Health Administration Processes for 

Responding to Reported Adverse Events, GAO-12-827R (Washington, D.C.: Aug. 24, 

2012). In this report we found that VAMCs may also use root cause analysis to evaluate 

the systems or process causes for an adverse event; we did not include root cause 

analysis in this report because we focused on the processes used to evaluate actions of 

individual providers, not processes used to address systems or process issues.

5

FPPEs are also conducted at the time of a provider’s initial appointment to the VAMC’s 

medical staff, or when a provider applies for new or additional privileges; we excluded 

these types of FPPEs from the scope of our review. Privileges are the authority granted to 

a physician or dentist by the VAMC to provide patient care in the facility. Privileges are 

limited by the VAMC’s capabilities and the individual’s professional license, education, 

training, experience, and competence. Hereafter, we use the term FPPE to refer to an 

FPPE conducted for cause, such as when questions arise about a privileged provider’s 

ability to deliver safe, quality care.
 

Page 3 GAO-14-55 VA Adverse Events

provider’s professional misconduct or from potential system deficiencies 

related to VHA policies or procedures.6

In evaluating the role of providers in adverse events, VHA emphasizes 

the use of protected processes that are confidential and nonpunitive, 

which they believe better facilitate quality management efforts at the 

individual provider level. The peer review for quality management is a 

protected process.7 The information collected is confidential and 

protected under federal law, and therefore cannot be used to inform 

adverse actions against providers, such as limiting a provider’s clinical 

privileges.

8 However, according to VHA officials, if a provider’s ability to 

provide safe, quality patient care is in question, then VAMCs may use a 

nonprotected process to address such concerns.9

 

6

An example of a system deficiency would be a failure of a VAMC’s pharmacy to ensure 

patients receive the prescribed medication.

FPPEs and AIBs are 

nonprotected processes, and, therefore, the information collected through 

these processes can be used to inform adverse actions against providers. 

When warranted on the basis of the outcome of these types of processes, 

VAMC officials may take a variety of actions, such as training and 

7

Hereafter, we refer to peer review for quality management as protected peer review.

8

Under federal law, records and documents created as part of VHA’s medical quality 

assurance program are confidential and privileged and may only be disclosed under 

limited circumstances. See 38 U.S.C. § 5705; 38 C.F.R. §§ 17.500-17.511. VHA’s medical 

quality assurance program consists of systematic health care reviews carried out by or for 

VHA for the purposes of improving the quality of medical care or improving the utilization 

of health care resources in VHA medical facilities. The protected peer review process is 

part of VHA’s medical quality assurance program, and, as such, documents generated 

through these processes are confidential and privileged.

9

VHA policy refers to nonprotected processes generally as management reviews.
 

Page 4 GAO-14-55 VA Adverse Events

proctoring a provider, major adverse actions, disciplinary actions, or 

privileging actions.10

Adverse events raise questions about the quality of care VAMCs provide 

to veterans. You asked us to review any gaps in the processes that 

VAMCs use for responding to adverse events and the extent to which the 

processes are carried out across VHA’s health care system. In this report, 

we examined

1. VAMCs’ adherence to VHA’s protected peer review process and the 

extent to which VHA monitors this process, and

2. VAMCs’ adherence to VHA’s nonprotected processes and the extent 

to which VHA monitors these processes.

To examine VAMCs’ adherence to protected and nonprotected 

processes, we reviewed VHA’s policies on protected peer review and 

FPPEs, and VA’s policy on AIBs.11 Additionally, we reviewed these 

processes in the context of federal internal control standards for risk 

assessment, information and communications, control activities, and 

monitoring.12

 

10According to VA policy, major adverse actions include suspension, transfer, reduction in 

grade, reduction in basic pay, and termination. Disciplinary actions include 

admonishments, which are official letters of censure for minor deficiencies in competence 

or conduct; and reprimands, which are more severe letters of censure for deficiencies in 

competence or conduct. Department of Veterans Affairs, Employee/Management 

Relations, VA Directive 5021, v.3 (Washington, D.C.: Aug. 28, 2007) and 

Employee/Management Relations, VA Handbook 5021, v.10 (Washington, D.C.: Nov. 8, 

2012), accessed April 17, 2013, http://www.va.gov/vapubs/search_action.cfm?dType=2). 

Privileging actions include reducing, revoking, suspending, denying, or failing to renew a 

provider’s privileges. Veterans Health Administration, Credentialing and Privileging, VHA 

Handbook 1100.19 (Washington, D.C.: Nov. 14, 2008).

We also visited four VAMCs, which were selected on the 

basis of geographic variation using the location in one of VA’s 21 

Veterans Integrated Service Networks (VISN) as a proxy, VAMC size 

11According to VHA officials, protected peer review and FPPE processes are specific to 

VHA. In contrast, the AIB process is used across VA, by VHA as well as VA’s other 

administrations—the Veterans Benefits Administration and the National Cemetery 

Administration.

12GAO, Internal Control Standards: Internal Control Management and Evaluation Tool, 

GAO-01-1008G (Washington, D.C.: Aug. 2001).
 

Page 5 GAO-14-55 VA Adverse Events

based on the number of unique patients served, and level of surgical 

complexity (see table 1).13

Table 1: VA Site Visit Locations and Characteristics

VA medical center

(VAMC) location

Veterans Integrated 

Service Network (VISN) VAMC sizea Surgical 

complexity ratingb

Dallas, Texas 17 112,000 Complex

Nashville, Tennessee 9 84,000 Complex

Seattle, Washington 20 87,000 Complex

Augusta, Maine 1 40,000 Intermediate

Source: GAO analysis of Veterans Health Administration (VHA) information.

a

Number of unique patients rounded to the nearest thousand.

b

VHA assigns each VAMC a surgical complexity rating of standard, intermediate, or complex. This 

classification system uses multiple variables to measure surgical complexity arrayed along four 

categories: facilities, equipment, workload, and staffing. These ratings were implemented May 7, 

2010.

We also requested data from each VAMC on protected peer reviews, 

FPPEs, and AIBs from fiscal years 2009 through 2011 in order to review 

the four VAMCs’ adherence to the applicable policies and within the 

context of relevant federal internal control standards.14 Specifically, we 

reviewed VAMCs’ adherence to several elements of VHA’s protected 

peer review policy for which VAMCs are required to collect data;15

 

13VISNs are regional systems of care that oversee the day-to-day functions of VAMCs that 

are within their network. Each VAMC is assigned to a single VISN. VHA assigns each 

VAMC a surgical complexity rating of standard, intermediate, or complex. This 

classification system uses multiple variables to measure surgical complexity arrayed along 

four categories, namely facilities, equipment, workload, and staffing load. For example, a 

hospital assigned a complex rating requires special facilities, equipment, and staff for 

difficult operations, such as cardiac surgery and organ transplants. We chose three sites 

with a complex rating and one with an intermediate rating, for variation.

these 

selected elements include timeliness of peer review completion and 

committee review of select peer review results. VHA requires VAMCs to

establish peer review or professional activity triggers that signal the need 

to conduct a detailed assessment of a provider’s care, which can then 

14Data from fiscal years 2009 through 2011 were the most recent data available at the 

time we initiated our review.

15Department of Veterans Affairs, Veterans Health Administration, Peer Review for Quality 

Management, VHA Directive 2010-025 (Washington, D.C.: June 3, 2010).
 

Page 6 GAO-14-55 VA Adverse Events

lead to an FPPE.

16 We reviewed only whether VAMCs established peer 

review triggers, since VAMCs collect peer review data.

17

We examined VAMCs’ adherence to VHA’s FPPE process by reviewing 

VAMCs’ available FPPE documentation for clarity and ease of tracking 

what steps the VAMC had taken to conduct the FPPEs from initiation to 

completion. We reviewed VA’s policy on AIBs and interviewed VAMC 

officials about their use of AIBs to investigate providers involved in 

adverse events. We also reviewed previous GAO work on VA’s AIB 

process, including the extent to which VA collected data on AIBs and how 

VA used the results of AIB investigations.

To assess the 

reliability of the protected peer review data we analyzed, we reviewed 

VHA’s protected peer review policy on data reporting requirements, 

interviewed VHA and VAMC officials familiar with the data, and conducted 

checks on the data, looking for missing values, outliers, or other 

anomalies. We found some records that contained missing, incomplete, 

or inaccurate data and excluded those data from our analysis. We 

determined that the deletions had no material effect on our analysis and 

that the data, as analyzed, were sufficiently reliable for our purposes.

18 We were unable to analyze 

VAMCs’ implementation of certain elements of VA’s AIB policy because 

at the time of our review VAMCs had not retained all of the 

documentation necessary for us to conduct a review for processes 

conducted from fiscal years 2009 through 2011. According to the AIB 

policy,19

 

16VHA Directive 2010-025. VHA refers to the detailed assessment as a focused review.

the investigation files need to be retained in accordance with 

applicable records retention schedules and, at a minimum, until any 

corrective action is completed and the time frame for any claims or 

17A peer review trigger typically is a threshold that is determined by the number and 

results of protected peer reviews within a specified time frame, usually 12 months, for a 

particular provider that indicates the need for further review of the provider’s patient care. 

While VHA’s protected peer review policy mentions professional activity triggers, it does 

not provide a definition or illustrative example of such triggers. According to a VHA official, 

a professional activity trigger is based on clinical actions or professional clinical decisions 

made by the practitioner in the episode of care under review.

18GAO, VA Administrative Investigations: Improvements Needed in Collecting and Sharing 

Information, GAO-12-483 (Washington, D.C.: Apr. 30, 2012).

19Department of Veterans Affairs, Administrative Investigations, VA Handbook 0700 

(Washington, D.C.: undated).
 

Page 7 GAO-14-55 VA Adverse Events

appeals has passed; we did not assess how long VAMCs should have 

kept each of the investigation files.20

To examine the extent to which VHA monitors VAMCs’ use of protected 

and nonprotected processes to respond to adverse events, we 

interviewed VHA officials from the Office of the Assistant Deputy Under 

Secretary for Health (ADUSH) for Quality, Safety and Value, including the 

Director of Risk Management and the Director of Credentialing and 

Privileging; the Office of the Deputy Under Secretary for Health for 

Operations and Management (DUSHOM); and the Office of the Medical 

Inspector. We also interviewed officials from the VA Office of Inspector 

General (OIG) Office of Healthcare Inspections, as well as the chief 

medical officers of the four VISNs for the VAMCs we visited.

We limited our review to describing VHA’s protected and nonprotected 

processes for responding to adverse events that involve individual 

providers, excluding from our scope processes, such as root cause 

analysis,21

We conducted this performance audit from July 2012 to December 2013 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

that focus primarily on events that involve systems or 

processes issues. We focused our review on VHA physicians and 

dentists, hereafter referred to as providers, because these are the primary 

types of licensed independent providers at VAMCs. The findings of our 

four site visits cannot be generalized to other VAMCs.

 

20Since this report covers fiscal years 2009 through 2011, the period of time covered by 

the applicable records retention schedule for AIB documentation might have passed by 

the time we requested the documentation.

21A root cause analysis is a process for identifying the basic or contributing factors that 

underlie variations in the performance of systems and processes.
 

Page 8 GAO-14-55 VA Adverse Events

VAMCs conduct an initial review of cases that are identified as possible 

adverse events to determine how best to respond and which process to 

use to determine the facts of the case, such as protected peer review, 

FPPE, or AIB. Because VAMCs generally have discretion in which of 

these processes they choose to use to respond to an adverse event, 

different VAMCs may choose different processes in response to 

experiencing similar adverse events. Based on the nature of the adverse 

event and the information gleaned through a particular review process, a 

VAMC may decide to conduct multiple types of reviews, both protected 

and nonprotected processes, as appropriate. Information collected 

through protected review processes, including protected peer review, 

cannot be used to inform adverse actions against a provider; information 

collected through nonprotected processes, including FPPEs and AIBs, 

can be used to support a VAMC’s decision to take adverse action against 

a provider. According to VHA policy, VAMCs can use both protected and 

nonprotected processes concurrently or consecutively as long as 

protected and nonprotected processes and data collection are kept 

separate. According to VHA officials, if a VAMC is using a protected 

process to review an event and realizes that a nonprotected review may 

be necessary, the protected process should be stopped and the VAMC 

should start a nonprotected review. See figure 1 for an illustration of the 

decision process a VAMC official might use when deciding how to 

respond to an adverse event.

Background 
 

Page 9 GAO-14-55 VA Adverse Events

Figure 1: Example of Decision Process Used by VA Medical Center (VAMC) Officials 

When Responding to an Adverse Event

According to VHA’s protected peer review policy, peer review is required 

under certain circumstances, such as a death that appears related to a 

hospital-incurred incident or a complication from treatment and a suicide 

within 30 days of a clinical encounter with a VA health care professional.22

 

22VHA Directive 2010-025.

Peer review may be considered in other circumstances, such as when 

there is an unexpected or negative outcome. Once VAMC officials decide 

to conduct a protected peer review, a peer reviewer is assigned to 

Protected Process
 

Page 10 GAO-14-55 VA Adverse Events

evaluate the care delivered and the actions taken by the provider.23

• Level of care 1 – the most experienced, competent providers would 

have managed the case in a similar manner;

The 

peer reviewer makes an initial determination of whether the provider 

should have taken different action when providing patient care and 

preliminarily assigns one of the following three levels of care:

• Level of care 2 – the most experienced, competent providers might 

have managed the case differently; or

• Level of care 3 – the most experienced, competent providers would 

have managed the case differently.

According to VHA’s peer review policy, the initial peer review should be 

completed within 45 calendar days from determination of the need for 

peer review.24 If the peer-reviewed case is assigned a level of care 2 or 3, 

it must be referred to the VAMC’s peer review committee for further 

review.25

 

23The peer reviewer is a provider who has relevant expertise necessary to make accurate 

judgments about the clinical event being reviewed, is able to make a fair and credible 

assessment, and has knowledge of relevant standards of care. According to VHA and 

VAMC officials, generally, a provider is peer-reviewed by another provider at the same 

VAMC and, if possible, within the same specialty.

After conducting a further review of the facts of the case, and 

receiving further input from the provider under review, the peer review 

committee either validates the initial level of care or assigns a higher or 

lower level of care. The peer review committee’s level of care rating is 

final and must be completed within 120 calendar days from determination 

of the need for peer review. The peer review committee can also make 

recommendations for nonpunitive, nondisciplinary actions, as appropriate, 

24Language referring to this 45 calendar day requirement was changed in the 2010 

version of VHA’s peer review policy from must to should be completed in 45 calendar 

days. According to the VHA Director of Risk Management, despite this change in policy 

language, VAMCs are still expected to complete initial peer reviews around the 45 day 

time frame. VHA’s protected peer review policy was updated in June 2010, which was 

during the time period we studied— fiscal years 2009 through 2011. For the previous 

version of VHA’s protected peer review policy, see Department of Veterans Affairs, 

Veterans Health Administration, Peer Review for Quality Management, VHA Directive 

2008-004 (Washington, D.C.: Jan. 28, 2008).

25The peer review committee is a multidisciplinary group that is chaired by the Chief of 

Staff and includes the Nurse Executive, senior members of key clinical disciplines, and

nonphysician members.
 

Page 11 GAO-14-55 VA Adverse Events

such as reviewing and revising local policy, to improve the quality of care 

delivered. The final level of care rating and any recommendations for 

improvement are reported to the provider’s supervisor, who gives the 

provider feedback that is based on the peer review committee’s findings. 

According to VHA officials, VAMCs conduct approximately 23,000 

protected peer reviews systemwide annually.

VHA also has a contract with an external organization that is used to audit 

protected peer review.26 VAMCs may request external protected peer 

review expertise if there are no qualified peers available at the VAMC. 

According to a VISN official, external review may also be requested if the 

VAMC needs to ensure an independent peer review, for example, if all 

the providers in the same clinical specialty were involved in the event. 

VHA also requires each VAMC to submit quarterly a sample of cases that 

were recently peer-reviewed, for a secondary peer review by this external 

organization.27

According to VHA’s protected peer review policy, each VAMC is required 

to develop peer review or professional activity triggers to signal the need 

for further assessment of a provider’s clinical care.28 The triggers are 

specific to an individual VAMC. If, after a detailed assessment, concerns 

arise about a provider’s ability to deliver safe, quality patient care, then an 

FPPE would be conducted.

29

 

26VHA contracted with Lumetra Healthcare Solutions to conduct external protected peer 

reviews of selected cases and to assess the accuracy of peer review conducted by 

VAMCs. According to VHA officials, the implementation of this contract started in fiscal 

year 2011. Lumetra Healthcare Solutions has a peer review network of over 250 

physicians and other clinical professionals.

For example, if a provider meets a VAMC’s 

peer review triggers by receiving three peer review level of care ratings of 

3—meaning that the most experienced, competent providers would have 

managed the cases differently—within a 12-month period, then VAMC 

officials would be prompted to conduct a detailed assessment of the 

27VAMCs that offer more complex clinical services are required to send 15 cases per 

quarter, and VAMCs that offer less complex clinical services are required to send 10 

cases per quarter, for this external audit.

28VHA Directive 2010-025.

29An FPPE can be initiated for reasons other than when a trigger is met or exceeded, 

such as when a VAMC official has a concern about the clinical actions or decisions made 

by a provider for the episode of care under review.
 

Page 12 GAO-14-55 VA Adverse Events

provider’s care, and address concerns about the provider’s ability to 

deliver safe, quality patient care by conducting an FPPE.

According to VHA policy, an FPPE may be used when a question arises 

regarding a provider’s ability to provide safe, quality patient care, such as 

whether documentation of patient encounters is late or insufficient, or 

whether diagnoses are accurate. An FPPE may also be used when a 

provider meets or exceeds a VAMC’s peer review triggers and a detailed 

assessment indicates the need for further review. According to VHA and 

VAMC officials, an FPPE begins by providing an opportunity for a 

provider to improve his or her performance in area(s) of identified 

concern. The FPPE is a time-limited period during which medical staff 

leadership assesses the provider’s professional performance and ability

to improve. According to VAMC officials, if the provider’s performance 

improves, VAMC officials may decide that the FPPE process is completed 

and the provider may be returned to routine monitoring. If a provider’s 

performance does not improve, then medical staff leaders may decide to 

continue the FPPE for an additional period of time or determine if a 

privileging action should be taken, such as reducing or revoking a 

provider’s privileges.30 The FPPE may include a review of the provider’s 

care, either through medical record review, direct observation, or 

discussions with other individuals involved in the care of patients. FPPEs 

conducted when a question arises regarding a provider’s ability to provide 

safe, quality patient care are not conducted often, according to VHA and 

VAMC officials. According to a VHA official, about 100 FPPEs of this kind 

are conducted VHA-wide each year.31

VA typically uses AIBs to examine nonclinical issues for which the facts 

are in dispute, such as allegations of employee misconduct, according to 

VHA and VAMC officials. These officials also said VAMCs may use AIBs 

to investigate issues of an individual provider’s clinical competence, but 

 

30A privileging action could include reduction, denial, nonrenewal, or revocation of 

privileges.

31These 100 FPPEs include only FPPEs conducted for cause and do not include FPPEs 

conducted for newly hired providers or for providers requesting new or additional 

privileges.

Nonprotected Processes
 

Page 13 GAO-14-55 VA Adverse Events

this is not typical.32 According to VA’s AIB policy, the convening 

authority—typically the VAMC director—appoints members to an AIB and 

defines the scope and authority of the investigation.33 The AIB collects 

and analyzes evidence and develops a report, including findings and 

conclusions. The VAMC director may use an AIB’s findings to inform 

decisions of whether to take adverse action against a provider and, if so, 

what type of action to pursue. In our 2012 report on AIBs, we found that 

VAMCs and VISNs conducted a total of 1,136 investigations nationwide 

from fiscal year 2009 through 2011, but because VA does not track the 

types of matters investigated, it is unclear how many of these were 

related to clinical competence.34

There are several VA and VHA organizational components that are 

involved in monitoring VAMCs’ adverse events and related processes. 

VHA’s Office of the ADUSH for Quality, Safety and Value is responsible 

for establishing VHA policies for protected peer review and FPPEs and 

for providing guidance to VAMCs on using those processes. VHA’s Office 

of the DUSHOM oversees the VISNs and provides the VISNs broad and 

general operational direction and guidance; VISN directors are tasked 

with oversight of the protected peer review process. The Office of the 

Medical Inspector addresses health care problems to monitor and 

improve the quality of care provided by VHA; veterans may report 

problems with medical care received at VAMCs directly to the Office of 

the Medical Inspector. The VA OIG Office of Healthcare Inspections 

inspects individual health care issues and performs quality program 

assistance reviews of VAMC operations. See figure 2 for a simplified 

organizational chart of the relationship among these entities.

 

32Clinical competence is the documented demonstration that an individual provider has 

the requisite or adequate abilities or qualities to perform up to a defined expectation in 

providing patient care.

33VA Handbook 0700.

34We recommended that VHA establish a process to collect and analyze aggregate data 

from AIB investigations, including the number of investigations conducted, the types of 

matters investigated, whether the matters were substantiated, and the systemic 

deficiencies identified. See GAO-12-483. 

VA and VHA Monitoring 

Responsibilities 
 

Page 14 GAO-14-55 VA Adverse Events

Figure 2: VA and Veterans Health Administration (VHA) Organizational Components 

Involved in Monitoring VA Medical Centers’ (VAMC) Adverse Events and Related 

Processes
 

Page 15 GAO-14-55 VA Adverse Events

According to VHA’s protected peer review policy, and supported by 

federal internal control standards for risk assessment and information and 

communications, VHA’s protected peer review policy requirements should 

ensure that identified patient safety risks are mitigated and lead to 

organizational improvements and optimal patient outcomes. Additionally, 

federal internal control standards state that agencies should have reliable 

information relating to internal events to effectively run and control their 

operations; this information should be identified, captured, and 

communicated in sufficient detail and at the appropriate time to the right 

people.

VAMC officials from all four sites we visited demonstrated a general 

understanding of the process as described in the protected peer review 

policy. For example, officials from each of the four VAMCs knew that peer 

review was a protected nonpunitive process and officials from three of the 

four VAMCs were able to describe the steps of the process. However, our 

analysis of peer review data for fiscal years 2009 through 2011 provided 

by the four VAMCs showed that none of the VAMCs adhered to all four 

VHA protected peer review policy elements selected for review: 

(1) completing the initial peer review within 45 calendar days, 

(2) completing the final peer review within 120 calendar days, (3) sending 

all initial level of care 2 and 3 peer reviews to the peer review committee, 

and (4) developing peer review triggers. Additionally, these peer review 

data included varying amounts of missing and inaccurate data, which 

affected our ability to fully analyze these data. See table 2 for a summary 

of the four VAMCs’ adherence to selected protected peer review policy 

elements.

VAMCs Did Not 

Adhere to Certain 

Policy Elements of 

the Protected Peer 

Review Process, and 

Monitoring by VHA Is 

Limited

VAMCs Did Not Adhere to 

Certain Policy Elements of 

the Protected Peer Review 

Process
 

Page 16 GAO-14-55 VA Adverse Events

Table 2: Adherence to Selected Protected Peer Review Policy Elements at Four VA 

Medical Centers (VAMC) GAO Visited, Fiscal Years 2009 through 2011

VAMC

Total number 

of protected 

peer reviewsa 

Percentage of 

initial peer 

reviews 

completed within 

45 calendar days

Percentage of final 

peer reviews 

completed within 

120 calendar days

Percentage of 

initial peer 

reviews rated 

level of care 2 

and 3 sent to peer 

review committee

A 262 77 89 100

B 354b 100 97c 99

C 1,000 Cannot determined Cannot determined 79e

D 307 79 89 96

Source: GAO analysis of Veterans Health Administration (VHA) data.

Note: Peer review level of care 2 means that the most experienced, competent provider might have 

managed the case differently; peer review level of care 3 means that the most experienced, 

competent provider would have managed the case differently.

a

These totals do not include peer-reviewed cases for which the date the case was initially sent to the 

peer reviewer was missing from VHA’s data. The total number of protected peer reviews for each 

facility does not reflect the numbers that were used to determine adherence for the three policy 

elements listed in this table. Each percentage calculation used a different denominator because of 

variations in the quality of the data sets across each of the policy elements and fiscal years.

b

Includes the number of protected peer reviews conducted in fiscal years 2010 and 2011 only, 

because the data for fiscal year 2009 were missing the date the peer review was sent and received 

by the peer reviewer.

c

Includes data from fiscal years 2010 and 2011 only. We could not determine adherence to this policy 

element because the data provided by this VAMC for fiscal year 2009 were missing the date the peer 

review was sent and received by the peer reviewer.

d

The peer review data provided by this VAMC for fiscal years 2009 through 2011 did not include the 

date the case was sent for initial peer review; it only included the date of the initial review. As a result, 

we could not determine whether initial peer reviews were completed within 45 calendar days or 

whether final peer reviews were completed within 120 calendar days for fiscal years 2009 through 

2011.

e

To determine the percentage of initial peer reviews rated level of care 2 and 3 sent to the peer 

review committee, we used evidence of a final peer review level as a proxy that a case was sent to 

the peer review committee for further review.

Completing initial peer reviews within 45 calendar days. In our 

analysis of the timeliness policy elements for fiscal years 2009 through 

2011, we found that VAMCs A and D completed 77 to 79 percent of initial 

peer reviews within 45 calendar days. VAMC B completed 100 percent of 

initial peer reviews within 45 calendar days for the 2 fiscal years for which 

data were available—2010 and 2011. We could not determine the 

completion percentage for VAMC C because the data provided by the 

facility did not contain all of the information needed. According to a VAMC 

C official, the peer review data provided to us was compiled just before 

our site visit and was based on a review of past records; the missing data 

elements could not be located during that review. Officials from VAMCs A 
 

Page 17 GAO-14-55 VA Adverse Events

and D told us that it was difficult to get peer reviewers to abide by the 

45-day rule, and, according to officials from VAMC D, the heavy workload 

of those in charge of peer review tracking during our study period affected 

their ability to ensure peer reviewers’ timely completion. According to the 

official in charge of peer review tracking at VAMC D, a routine process is 

now in place at this facility to remind peer reviewers to complete their 

reviews after 30 of the 45 calendar days allotted have elapsed.

Completing the final peer reviews within 120 calendar days. VAMCs 

A and D each completed 89 percent of final peer reviews within 120 

calendar days for fiscal years 2009 through 2011; VAMC B completed 

97 percent for fiscal years 2010 through 2011.35

Sending level of care 2 and 3 peer reviews to the peer review 

committee. We found that VAMCs A and D sent 96 to 100 percent of 

their initial level of care 2 and 3 peer reviews to the peer review 

committee for fiscal years 2009 through 2011; VAMC B sent 99 percent 

for fiscal years 2010 through 2011.

As previously noted, we 

were unable to determine the completion percentage for VAMC C. An 

official at VAMC A told us that, in addition to the delays in completing the 

initial peer reviews within 45 calendar days, the peer review committee 

might not have always been able to review all peer-reviewed cases at its 

monthly meeting if there had been a particularly large number of cases 

sent to the committee that month.

36 VAMC C sent 79 percent of its initial 

level of care 2 and 3 peer reviews to the peer review committee. Officials

from VAMC C told us that a possible reason for the low adherence rate 

could be that the peer review committee and one of the VAMC’s service 

line committees tasked with sending level of care 2 and 3 cases to the 

peer review committee for further review did not communicate well during 

this time period. According to these officials, communication and 

coordination between these two committees has recently improved.

 

35The VA Office of Inspector General (OIG) found in its report focusing on one of the sites 

we visited that 2 percent of final peer reviews exceeded the 120 calendar day time frame 

and extensions had not been requested or approved. This was a repeat finding from the 

VA OIG’s previous review.

36This requirement did not change from the 2008 to the 2010 version of VHA’s peer 

review policy.
 

Page 18 GAO-14-55 VA Adverse Events

Developing peer review triggers. We found that some VAMCs did not 

develop peer review triggers in a timely way. VHA’s protected peer review 

policy issued in January 2008 required that VAMCs develop criteria that 

may define the need for further review or action.37

We found that while all four VAMCs we visited developed peer review 

triggers, two of the four VAMCs developed peer review triggers 

approximately two years after the updated policy was issued. (See 

table 3.)

VHA’s 2010 update of 

this policy specified that VAMCs were required to establish peer review or 

professional activity triggers. The 2010 policy update provides one 

example of what these triggers could include—three peer review level of 

care 3 ratings for a provider within 12 consecutive months. Further, 

federal internal control standards for risk assessment state that 

management should identify internal risks and undertake a thorough and 

complete analysis of the possible effects. Additionally, the standards state 

that risk assessment should include establishment of criteria for 

determining low, medium, and high risk levels.

Table 3: Date Established and Description of Peer Review Triggers at Four VA 

Medical Centers (VAMC) GAO Visited

VAMC

Date trigger 

established Description of trigger

A May 2012 Three level of care 3s within 12 consecutive months 

B July 2008 Two level of care 3s or four level of care 2s within 

12 consecutive months

C August 2012 Two level of care 3s or three level of care 2s within 

12 consecutive months

D December 2010 Two level of care 3s or three level of care 2s within 

6 consecutive months

Source: GAO analysis of VHA data.

Note: Peer review level of care 2 indicates that the most experienced, competent provider might have 

managed the case differently. Peer review level of care 3 indicates that the most experienced, 

competent provider would have managed the case differently.

 

37VHA Directive 2008-004.
 

Page 19 GAO-14-55 VA Adverse Events

According to some VAMC officials we spoke with, the delay in developing

peer review triggers was the result, at least in part, of a lack of guidance 

from VHA. When asked about peer review triggers, officials from VAMCs 

B and C told us they did not receive any assistance from VHA in 

developing triggers and that the guidance provided by VHA was vague. 

Officials from VAMCs A and C, the two VAMCs that did not initially 

develop peer review triggers, told us that while they had informal triggers 

that could prompt the need for a nonprotected review, such as an FPPE,

they had not formally documented the triggers.

When VAMCs fail to complete peer reviews in a timely manner and send 

all level of care 2 and 3 initial peer reviews to the peer review committee, 

they put patients’ safety at risk through potential exposure to substandard 

care. VAMCs may fail to identify problematic providers in a timely manner 

and take the appropriate actions. Additionally, by not submitting initial 

level of care 2 and 3 peer reviews to the peer review committee for further 

evaluation, VAMCs are not ensuring that the initial ratings assigned were 

appropriate. Moreover, the delayed establishment of the peer review 

triggers by some VAMCs may have resulted in missed opportunities to 

identify providers who posed a risk to patient safety and to conduct an 

FPPE, which would have allowed any warranted action to be taken 

against the provider.

Within VHA, the VISNs and the Office of Risk Management monitor 

VAMCs’ protected peer review processes. Officials from the VISNs that 

oversee the four VAMCs we visited told us they monitor VAMCs’ 

protected peer review processes through quarterly data monitoring and 

annual site visits, as required by VHA’s protected peer review policy.38

Officials from these VISNs said they monitor peer review data that 

VAMCs are required to submit quarterly.39

 

38VHA’s peer review policy requires that VISNs conduct and complete annual and ad hoc 

site visits, ensure peer review data are collected, analyzed, and acted upon, and ensure 

peer review data are loaded quarterly into a shared database. See VHA Directive 2010-

025.

Data elements that are to be 

submitted by VAMCs and reviewed by the VISN include, but are not 

limited to, the number of peer reviews completed, the assigned level of 

care ratings by the initial peer reviewer and by the peer review committee, 

39VHA Directive 2010-025.

VHA and VA OIG Monitor 

VAMCs’ Protected Peer 

Review Process
 

Page 20 GAO-14-55 VA Adverse Events

the number of assigned level of care ratings changed to a higher or lower 

level by the peer review committee, and the timeliness of the reviews. 

After completing their review of VAMCs’ quarterly data, VISN officials are 

to send aggregated peer review data to VHA’s office of the ADUSH for 

Quality, Safety and Value through a shared electronic database.

In addition to quarterly review of the data, officials from all four VISNs 

said they conduct annual site visits to the VAMCs within the VISN; these 

site visits include a multifaceted review of VAMCs’ quality management 

operations. However, we did not review documentation from the VISNs’ 

site visits; one VISN official told us that the VISN does not keep formal 

records and that it is required only to attest to their completion. The scope 

of VISNs’ annual site visits covers a broad variety of topics, including 

VAMCs’ protected peer review processes, according to VISN officials. All 

VISN officials we spoke with told us they typically chose which elements 

of the peer review process to review based on the focus of recent 

inspections by other entities, such as The Joint Commission and the VA 

OIG.40

The Director of Risk Management told us the Office of Risk Management 

monitors protected peer review processes by reviewing and analyzing 

aggregated data submitted quarterly by VAMCs through the VISNs, as 

required by VHA’s protected peer review policy.

For example, officials we spoke with from one of the four VISNs 

said they reviewed in a 2012 site visit whether the VAMCs implemented 

the protected peer review policy elements for timeliness—specifically, 

completing final peer reviews within 120 calendar days; VA OIG reported 

in January 2011 that a VAMC within the VISN was not compliant with this 

timeliness requirement.

41

 

40The Joint Commission is an independent, not-for-profit organization that accredits and 

certifies more than 20,000 health care organizations and programs in the United States, 

including VAMCs. According to VHA’s policy on protected peer review, VAMCs’ protected 

peer review processes must comply with accreditation requirements of The Joint 

Commission.

The Director of Risk 

Management told us a staff member in that office reviews the data at the 

VISN and VAMC levels, including the total number of peer reviews; initial 

peer review level of care 1, 2, or 3 ratings; total number of peer reviews 

sent to the peer review committee; and number of peer reviews with the 

41VHA’s protected peer review policy requires VHA to conduct analysis of peer review 

data findings submitted by each VISN and to disseminate those findings to the Under 

Secretary for Health, VISNs, and other leadership. See VHA Directive 2010-025.
 

Page 21 GAO-14-55 VA Adverse Events

rating level of care changed by the peer review committee. The Director 

of Risk Management said that if an outlier is identified in the aggregated 

data, it is brought to the attention of the relevant VISN officials. An official 

from the Office of Risk Management reported that the office produces 

quarterly reports from analysis of the VHA systemwide aggregated 

protected peer review data and that these quarterly reports are shared 

with each VISN. According to VHA’s fourth quarter report for fiscal year 

2012, ratings for 22 percent of peer-reviewed cases were changed by the 

VAMCs’ peer review committees. VHA’s analysis found that the peer 

review committees were more likely to improve the peer review rating by 

decreasing the assigned rating level, such as decreasing a level of care 3 

to a level of care 1 or 2, or a level of care 2 to a level of care 1.

In addition to monitoring VISNs’ aggregated protected peer review data, 

VHA’s Director of Risk Management said the office communicates 

regularly with the Office of the DUSHOM, as required by VHA’s protected 

peer review policy and supported by federal internal control standards for 

information and communications. According to VHA’s protected peer 

review policy, the DUSHOM’s responsibilities include establishing and 

maintaining the peer review program in coordination with the ADUSH for 

Quality, Safety and Value, and providing direction and guidance on data 

elements that VAMCs must report through VISNs to VHA.42 Federal 

internal control standards state that mechanisms should exist to allow the 

easy flow of information down, across, and up through the organization, 

and easy communications should exist between functional activities. 

These standards also state that responsibility for decision-making should 

be clearly linked to the assignment of authority, and individuals should be 

held accountable accordingly.43

Beyond VHA monitoring of VAMCs’ protected peer review process, the 

VA OIG also routinely reviews certain policy elements of the process 

through its Combined Assessment Program, which reviews each VAMC 

The Director of Risk Management said 

that the office periodically gives brief overviews of the office’s work, 

including protected peer review findings, to the Under Secretary for 

Health and to the DUSHOM.

 

42VHA Directive 2010-025.

43GAO-01-1008G. 
 

Page 22 GAO-14-55 VA Adverse Events

every 2 to 3 years.44 In the last 5 years, the VA OIG has reviewed 

VAMCs’ compliance with several requirements, including (1) peer review 

committee must submit quarterly reports to the medical executive 

committee,45 (2) peer review committee must analyze protected peer 

reviews for trends in follow-up items and recommendations, and 

(3) protected peer reviews by the initial reviewer and the peer review 

committee must be completed timely. The VA OIG has conducted at least 

one Combined Assessment Program review since 2011 at each of the 

four VAMCs we visited.46 See table 4 for a summary of protected peer 

review monitoring activities conducted by VISNs, VHA’s Office of Risk 

Management, and VA OIG.

 

44VA OIG conducts Combined Assessment Program reviews that provide cyclical 

oversight of VAMCs and are used to review selected clinical and administrative 

operations.

45The medical executive committee is the primary governance committee for the medical 

staff at the VAMC. The medical executive committee, with input from the medical staff, 

makes key leadership decisions related to medical staff policies, procedures, and rules, 

with an emphasis on quality control and quality improvement initiatives. According to 

VHA’s protected peer review policy, the medical executive committee is responsible for 

utilizing data from the peer review committee to determine the need for further action.

46For examples of VA OIG Combined Assessment Program reports for the four sites, see 

Department of Veterans Affairs, Office of Inspector General Office of Healthcare 

Inspections, Combined Assessment Program Review of the VA Puget Sound Health Care 

System, Seattle, Washington, Report No. 11-04569-141 (Washington, D.C.: Apr. 3, 2012); 

Department of Veterans Affairs, Office of Inspector General Office of Healthcare 

Inspections, Combined Assessment Program Review of the Tennessee Valley Healthcare 

System, Nashville, Tennessee, Report No. 12-02185-288 (Washington, D.C.: Sept. 27, 

2012); Department of Veterans Affairs, Office of Inspector General Office of Healthcare 

Inspections, Combined Assessment Program Review of the VA North Texas Health Care 

System, Dallas, Texas, Report No.12-01875-245 (Washington, D.C.: Aug. 13, 2012); and 

Department of Veterans Affairs, Office of Inspector General Office of Healthcare 

Inspections, Combined Assessment Program Review of the VA Maine Healthcare System, 

Augusta, Maine, Report No. 12-03741-61 (Washington, D.C.: Dec. 12, 2012).
 

Page 23 GAO-14-55 VA Adverse Events

Table 4: Protected Peer Review Process Monitoring Activities by Selected VA and 

Veterans Health Administration (VHA) Organizational Components

VA/VHA organizational component Data monitoring Site visits

VHA Office of Quality, Safety and Value, Office of Risk 

Management

X 

Veterans Integrated Service Networks (VISN) X X 

VA Office of Inspector General Office of Healthcare 

Inspections

X 

Source: GAO.

According to officials from the Office of Risk Management, routine 

monitoring of certain policy elements of VAMCs’ protected peer review 

processes has enabled VHA to make changes in policy and improve 

protected peer review monitoring activities. VHA’s Director of Risk 

Management said that her office is responsible for making changes to 

policy in response to VA OIG findings related to the protected peer review 

process. For example, in a 2008 report on VISNs’ oversight of the 

protected peer review process, the VA OIG found that VISNs failed to 

substantially comply with the requirement to conduct periodic inspections; 

the VA OIG recommended that VHA clarify its peer review policy to define 

periodic site visits required of VISNs.47 VHA’s 2008 revision of the 

protected peer review policy redefined site visits as annual to result in 

more frequent monitoring by VISNs.48

 

47Department of Veterans Affairs, Office of Inspector General, Healthcare Inspection: 

Veterans Integrated Service Network Oversight of Peer Review Processes, Report 

No. 08-00338-115 (Washington, D.C.: Apr. 22, 2008).

VHA also improved peer review 

data monitoring activities. According to the Director of Risk Management, 

a national survey of VAMC risk managers was conducted in 2011 to 

better understand how protected peer review data are used. Based on 

survey data and a literature review, VHA officials said they determined 

that VAMCs and VISNs needed additional data on the specific areas of 

care that were being peer-reviewed as well as information about 

significant problems identified and frequently cited issues. VHA officials 

said that in fiscal year 2012, they expanded the required quarterly 

protected peer review data set that VAMCs report to the VISN to include 

the commonly peer-reviewed aspects of care, such as the choice of a 

48VHA Directive 2008-004.
 

Page 24 GAO-14-55 VA Adverse Events

diagnostic test, performance of a procedure or treatment, and addressing 

abnormal results of diagnostic tests.

According to VHA’s protected peer review policy, VISNs and the Office of 

Risk Management play a role in monitoring VAMCs’ implementation of 

protected peer review processes, which include peer review triggers. In 

addition, federal internal control standards state that management needs 

to comprehensively identify risks and analyze the possible effects; these 

peer review triggers serve as part of VHA’s risk assessment tool to help 

identify issues of risk to patient safety and improve the organization.49

Officials of the VISNs for the four VAMCs we visited and the VA OIG told 

us they have reviewed the establishment of peer review triggers by 

VAMCs. However, VISNs, VHA, and VA OIG have not monitored whether 

the triggers have actually been implemented. Officials we interviewed 

from two of the four VISNs said their VISNs reviewed VAMCs’ peer 

review triggers during the required annual site visits; an official from a 

third VISN said that the VISN has confirmed that most VAMCs have 

established peer review triggers. Officials from the fourth VISN told us 

they have reviewed types of triggers in place at VAMCs, but they have 

not confirmed that VAMCs have established peer review triggers. Officials 

from all four VISNs told us they typically do not monitor whether VAMCs 

have implemented the established peer review triggers, including 

monitoring how many FPPEs for cause have been triggered. One VISN 

official explained that the VISN cannot monitor every aspect of every 

policy and regulation that govern VAMCs’ operations; therefore, they 

choose to focus their monitoring efforts on the elements of particular 

importance where other entities—such as the VA OIG and The Joint 

Commission—have found evidence of noncompliance.

VHA’s Director of Risk Management told us that the office does not 

monitor whether VAMCs have established peer review triggers. Further, 

the official told us the office has not monitored how VAMCs have 

implemented peer review triggers or tracked how many providers may be 

exceeding the triggers and are subject to FPPEs for cause. The official 

also noted that VHA has not asked VAMCs to document their peer review 

triggers and has not asked the VA OIG to look specifically, during 

 

49GAO-01-1008G. 

VHA and VA OIG 

Monitoring of Peer Review 

Triggers Is Limited
 

Page 25 GAO-14-55 VA Adverse Events

Combined Assessment Program reviews, at whether VAMCs have 

established triggers.

Officials from the VA OIG told us they did monitor VAMCs’ establishment 

of peer review triggers as part of Combined Assessment Program reviews 

conducted in fiscal year 2009. The OIG review found 97 percent 

compliance with establishing peer review triggers across the 44 VAMCs 

OIG officials visited; the four VAMCs we visited were not among the 44 

VAMCs included in this review.50 According to VA OIG officials, they 

decided not to review the establishment of peer review triggers in 

subsequent Combined Assessment Program reviews because of the high 

compliance rate in 2009; instead, subsequent Combined Assessment 

Program reviews focused on requirements with which VAMCs had not 

been in compliance, such as requiring the peer review committee to 

submit quarterly reports on protected peer review to the medical

executive committee.51,52

Because neither VHA’s Office of Risk Management nor VA OIG review 

whether peer review triggers have been implemented, VHA cannot 

provide reasonable assurance that VAMCs are using the triggers as a risk 

assessment tool as intended. Failure to do so weakens VAMCs’ ability to 

ensure patient safety, and officials cannot be assured that the use of 

these triggers meets the intended goal of identifying providers that are not 

delivering safe, quality patient care.

VA OIG officials told us they have not reviewed 

whether VAMCs have implemented the triggers.

 

50Department of Veterans Affairs, Office of Inspector General, Healthcare Inspection: 

Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 

2009, Report No. 09-00069-161 (Washington, D.C.: June 2, 2010). OIG officials confirmed 

that none of the four VAMCs included in our site visits were part of their sample of 44 

VAMCs in the fiscal year 2009 Combined Assessment Program reviews.

51The VA OIG found that 35 of the 44 VAMC peer review committees submitted quarterly 

reports to their medical executive committees as required. See VA OIG Report No. 09-

00069-161. 

52Department of Veterans Affairs, Office of Inspector General, Combined Assessment 

Program Summary Report, Evaluation of Quality Management in Veterans Health 

Administration Facilities Fiscal Year 2011, Report No. 11-00104-186 (Washington, D.C.: 

May 17, 2012). See also Department of Veterans Affairs, Office of Inspector General, 

Combined Assessment Program Summary Report, Evaluation of Quality Management in 

Veterans Health Administration Facilities, Fiscal Year 2012, Report No. 12-01480-183 

(Washington, D.C.: Apr. 25, 2013). 
 

Page 26 GAO-14-55 VA Adverse Events

FPPEs. According to federal internal control standards for control 

activities, written documentation should exist for all significant events that 

occur within an agency; this documentation should be readily available for 

examination, and it should be complete and accurate in order to facilitate 

tracing the event from initiation through processing to completion. In 

documenting FPPEs, building strong and complete evidence on each 

case is important to support the outcome of the evaluation, as well as to 

track the identified area of concern over time.

VHA’s FPPE policy provides a general definition of an FPPE, that it can 

be used for cause (when a question arises regarding a provider’s ability to 

provide safe, quality patient care), that the criteria for the FPPE should be 

defined by the VAMC in advance, and that the results of the FPPE must 

be documented in the provider’s profile.53

 

53Provider profiles consist of practitioner-specific data utilized to assist service chiefs and 

medical staff leadership in the privileging process. These profiles contain physician 

performance information collected through VAMC continuous monitoring efforts.

However, there are gaps in 

VHA’s policy regarding how these evaluations should be documented and 

what information should be included, which limited our ability to assess 

VAMCs’ adherence to the FPPE policy. Officials from two of the VAMCs 

we visited told us there are no standardized guidelines on how the FPPE 

process should be structured. According to the Director of Credentialing 

and Privileging, VHA’s policy on FPPEs was intended to allow VAMCs 

flexibility in the design of the evaluation to accommodate the variety of 

VAMC’s Adherence to 

the FPPE Process Is 

Unclear Due to Gaps 

in Policy Addressing 

Documentation 

Requirements; VHA 

Does Not Routinely 

Monitor Nonprotected 

Processes 

Gaps in Policy Create Lack 

of Clarity as to How 

VAMCs Are to Document 

the FPPE Process; 

Requirements for AIBs 

Generally Are Clear
 

Page 27 GAO-14-55 VA Adverse Events

ways that issues are identified and the types of issues that may be 

addressed (see box for example of an FPPE).

Officials from the VAMCs we visited were generally aware that FPPEs 

can be used to address concerns about the quality of a provider’s care; 

are time limited; and are not disciplinary, but could ultimately be used to 

take adverse action against a provider, if necessary. While VAMC officials 

were generally aware of the FPPE process, we found that the four 

VAMCs we visited varied widely in their documentation of FPPEs, 

attributable at least in part to the lack of specificity in VHA’s FPPE policy 

regarding documentation requirements. In reviewing FPPEs conducted 

between fiscal years 2009 and 2011 we found the following:

• One of the four VAMCs provided a completed template for each of its 

FPPEs, including the purpose of the FPPE, specifying what triggered 

the review, the time period for review, comments by the evaluator, an 

action plan based on the review, and evidence of concurrence with 

the review by the applicable service chief. (See app. I for an example 

of an FPPE template used at one of the VAMCs we visited.) 

• Two other VAMCs provided various combinations of documents as 

evidence of their FPPEs, including professional standards board 

minutes and emails and letters from evaluators. These documents 

contained varying amounts of information detailing the circumstances 

prompting the FPPE, comments from evaluators, and follow-up 

actions, if any.54

• The fourth VAMC initially provided us with documentation of one 

FPPE, including a completed template identifying the clinical service 

involved, the method of evaluation, the evaluator’s findings, and the 

service chief’s conclusions; and several documents, each with 

focused professional practice evaluation labeled at the top, specifying 

the medical records evaluated for the FPPE and the evaluator’s 

comments on each case. The VAMC’s service chief told us that an 

FPPE had been conducted for cause for this provider, but the VAMC’s 

quality manager said a formal FPPE had not been conducted and that 

the documentation we received was part of a protected peer review 

 

54From three of the four VAMCs, we received documentation for a total of 12 FPPEs from 

fiscal years 2009 through 2011 conducted in response to questions that arose regarding a 

provider’s ability to provide safe, quality patient care.

Example of an FPPE at one VAMC we 

visited 

There are multiple ways that an FPPE may be 

prompted, including multiple patient 

complaints or exceeding a VAMC’s peer 

review trigger. At one VAMC we visited, a 

provider exceeded a peer review trigger—

receiving two or more level of care 3 peer 

review ratings within 6 months—which 

prompted a detailed assessment, including a 

retrospective evaluation of 25 percent of the 

provider’s medical records over the previous 

12 months. The medical records were 

evaluated specifically for patient evaluations, 

outcomes, and documentation. Upon 

completion of the assessment, VAMC officials 

determined that the provider’s documentation, 

including patient discharge summaries, 

patient transfer, medication review, and 

disclosure notes, was inadequate. An FPPE

was initiated, for which the provider was 

instructed on how to properly document these 

types of summaries and notes. The evaluator 

also recommended that the provider write the 

notes for each patient seen before moving to 

see other patients, instead of writing the notes 

for all patients at the end of the day. VAMC 

officials also initiated a performance 

improvement plan for the provider, which 

included monitoring his medical record 

documentation over a 6-month period. When 

officials determined that the provider had not 

improved after this period, the FPPE was 

extended to continue monitoring aspects of 

his clinical care. The provider retired 6 months 

later.
 

Page 28 GAO-14-55 VA Adverse Events

process. This disagreement illustrates that even within the same 

facility the interpretation of VHA’s policy on FPPEs differs, which can 

lead to potentially inappropriate use.

Gaps in VHA’s policy on FPPE documentation requirements create a lack 

of clarity and therefore may affect VAMCs’ ability to appropriately 

document the evaluation of providers’ skills, support any actions initiated, 

and track provider-specific FPPE-related incidents over time. For 

example, if FPPEs are not well documented, VAMC officials may have 

limited knowledge of the findings to proceed with any actions and limited 

ability to track that such evaluations were conducted. As a result, if 

another adverse event subsequently occurred involving the same 

provider, the VAMC may not be aware of any prior findings. One VAMC 

official stressed to us the importance of thorough documentation of an 

FPPE, even if the determination is made that the provider delivered safe, 

quality patient care and no adverse action is needed. Without adequate 

documentation, a VAMC may conduct an FPPE that complies with VHA’s 

policy, and determine that adverse action is needed on the basis of the 

evaluation’s findings, but ultimately may be unable to take the action 

because the documented evidence is insufficient. Officials at one VAMC 

said they did not believe that the evidence gathered from an FPPE was 

strong enough to hold up against a provider’s appeal of an adverse 

action.

AIBs. Another type of nonprotected review that VAMC officials may 

choose to address an adverse event is an AIB.55 In our review of VA’s 

AIB policy, we found that the policy generally provides clear guidance on 

the requirements, including documentation. For example, the policy 

specifies steps on how VAMC officials determine the need for an AIB,

select the board members, and write the charge letter that convenes the 

AIB, and also provides a number of templates and checklists, including 

templates for the charge letter and investigative report, and checklists for 

collecting evidence, conducting interviews, and writing the report.56

 

55According to VAMC officials, although AIBs can be used to address issues of clinical 

competence, they are not usually used in these cases. They said a protected peer review 

or another nonprotected review process, such as an FPPE, would more likely be used to 

address clinical competence issues. 

56We identified five AIBs used to investigate potential problems with a provider’s patient 

care occurring during fiscal years 2009 through 2011 from two of the four VAMCs we 

visited.
 

Page 29 GAO-14-55 VA Adverse Events

When asked about AIBs, VAMC officials told us an AIB could be used 

when (1) a case is egregious; (2) there is a previous incident involving the 

same provider; (3) the VAMC needs or wants to take privileging or 

disciplinary action; and (4) the facts of a case are in dispute or when there 

is a high level of complexity and ambiguity in the case. For example, at 

one VAMC we visited, an AIB was convened to investigate the facts and 

circumstances regarding the care and treatment immediately preceding a 

veteran’s death. The AIB was charged with investigating allegations that a 

provider’s care deviated from standard practice procedures, including 

prescribing inappropriate doses of medications, not ensuring appropriate 

monitoring or appropriate interval of physical assessments, and providing 

substandard documentation and communication. 

FPPEs. According to federal internal control standards for monitoring, 

agencies should assess the quality of performance over time and provide 

reasonable assurance that deficiencies are detected and promptly 

resolved. Further, VHA’s credentialing and privileging policy states that 

the DUSHOM is responsible for ensuring that VISN directors maintain an 

appropriate credentialing and privileging process, which includes FPPEs, 

consistent with VHA policy.57

Officials we interviewed from three of the four VISNs told us they do not 

monitor FPPEs conducted in response to questions about a provider’s 

ability to deliver safe, quality patient care. Officials from two of those three 

VISNs said that they have examined a sample of FPPEs during annual 

site visit reviews of VAMC operations; however, the sample of FPPEs 

would include mostly FPPEs for newly hired providers, since there are 

very few FPPEs conducted in response to questions that have arisen 

about a provider’s ability to deliver safe, quality patient care. An official 

from the fourth VISN said he monitors FPPEs during annual site visits to 

The VISN Chief Medical Officer is 

responsible for oversight of the credentialing and privileging process of 

the VAMCs within the VISN.

 

57According to VHA’s credentialing and privileging policy, the DUSHOM’s monitoring of 

credentialing and privileging must continue through periodic site visits by The Joint 

Commission and other reviews as applicable. See VHA Directive 1100.19. VHA’s Director 

of Credentialing and Privileging told us that VHA policy does not specify a process or 

authority for monitoring FPPEs. However, although the policy does not mention monitoring 

of FPPEs specifically, FPPEs are part of the overall credentialing and privileging process.

VHA Does Not Routinely 

Monitor Nonprotected 

Processes
 

Page 30 GAO-14-55 VA Adverse Events

VAMCs, including FPPEs conducted in response to questions that have 

arisen about a provider’s ability to deliver safe, quality patient care.

Officials from the office of the DUSHOM and the Office of Credentialing 

and Privileging said they do not monitor FPPEs conducted in response to 

questions about a provider’s ability to deliver safe, quality patient care. 

The Office of Credentialing and Privileging does not monitor these FPPEs 

because there are so few of them that the cost of reviewing a process 

that occurs so infrequently would outweigh the benefit. According to VHA 

officials, if an FPPE leads to a proposed reduction or revocation of clinical 

privileges, the Director of Credentialing and Privileging is frequently 

consulted to ensure that appropriate due process is afforded the 

provider.58

Similar to the VISNs, VA OIG officials told us they do not monitor FPPEs 

conducted when a question arises regarding a provider’s ability to deliver 

safe, quality patient care. However, VA OIG officials said that, during site 

visits for Combined Assessment Program reviews, they do review policy 

elements of the process for FPPEs for providers newly appointed to the 

VAMCs’ medical staff or for providers requesting new privileges.59

AIBs. Officials from two of the four VISNs we interviewed said they 

routinely monitor VAMCs’ AIB activity, including confirming whether the 

AIBs were completed timely and what kinds of issues were addressed. 

Officials from the other two VISNs said they do not monitor AIBs. 

Because the AIB directive is a VA policy, there are no explicit 

Because none of these entities monitor FPPEs conducted when a 

question arises regarding a provider’s ability to deliver safe, quality 

patient care, VHA cannot be assured that the process is working as 

intended or whether VAMCs need additional guidance or training about 

the process.

 

58VA policy affords due process to providers prior to any privileging action. Providers are 

given the right to reply to a proposed privileging action prior to a final action. Once the 

VAMC director makes a final determination on a privileging action, the provider is entitled 

to a fair hearing by a panel of peers. If a privileging action is sustained following a fair 

hearing, providers have the right to appeal the decision to the VISN director, who may 

ultimately sustain or reverse the privileging action.

59According to a VA OIG official, these policy elements include whether there is evidence 

that FPPEs for new providers or new privileges are initiated, completed, and reported to 

the medical executive committee. 
 

Page 31 GAO-14-55 VA Adverse Events

requirements for VHA to monitor AIBs; however, federal internal control 

standards for information and communications state that relevant, 

reliable, and timely information is needed by an agency to achieve its 

objectives and to control its operations.60 In our 2012 report on AIBs, we 

found that VA does not collect and analyze aggregated data on AIB 

investigations, and at that time, VHA officials told us that there were no 

plans to do so.61 In our report, we recommended that VA establish a 

process to collect and analyze aggregated data from AIB investigations 

conducted within VHA. Having these types of data may provide VA with 

valuable information to systematically gauge the extent to which matters 

investigated by AIBs are occurring throughout VHA and to take corrective 

action, if needed, to reduce the likelihood of future occurrences. 

According to VHA officials, after our 2012 report was issued, VHA created 

a workgroup to examine our recommendation and concluded that 

monitoring AIBs was not necessary or warranted.

VAMCs’ adherence to policies on protected and nonprotected processes 

for responding to providers’ actions that contribute to adverse events 

helps ensure that quality care is provided to veterans and that safety risks 

are minimized. Having clear and detailed guidance in policy for these 

processes is critical to helping VAMC officials identify and address 

adverse events, including providers’ contributing actions, in a timely and 

appropriate manner. Although officials at the four VAMCs we reviewed 

generally understood the protected peer review process, we found that 

none of these four VAMCs adhered to all four VHA protected peer review 

policy elements selected for review, such as completing peer reviews 

within required time frames and sending the required peer-reviewed 

cases to the peer review committee for further assessment. As such, VHA 

may be missing opportunities for improvements both in the practice of 

individual providers and organizationally. VHA also may be missing 

opportunities to identify and intervene early with providers whose care 

may pose a risk to patient safety if VAMC officials have not established or 

implemented peer review triggers that would initiate a detailed 

assessment of a provider’s care. Assisting with and monitoring VAMCs’ 

development and use of these peer review triggers will help VHA ensure 

that the protected peer review process contributes to organizational 

 

60GAO-01-1008G. 

61GAO-12-483. 

Conclusions 
 

Page 32 GAO-14-55 VA Adverse Events

improvements and favorable patient outcomes, as intended by VHA 

policy.

FPPEs and AIBs are nonprotected processes that VAMCs use to address 

adverse events involving individual providers. However, gaps in VHA’s 

FPPE policy on documentation requirements have created a lack of 

clarity for VAMCs on how to appropriately document the process. 

Inadequate documentation of the FPPE process may result in VAMC 

officials being unable to take adverse action against a provider when 

necessary. Providing more specific policy guidance for FPPEs would 

better support VAMCs’ use of this process, including when officials 

determine that they may need to take adverse action against a provider. 

Although VHA officials reiterated that they do not have plans to collect 

and analyze aggregated AIB data as we recommended in our 2012 

report, we continue to believe that this is a potentially important quality 

improvement tool for use by VHA.

To improve VHA’s use of the protected peer review and nonprotected 

processes to respond to individual providers involved in adverse events 

or when questions arise regarding providers’ ability to deliver safe, quality 

patient care, we are making five recommendations. 

To address protected peer review process requirements, we recommend 

that the Secretary of Veterans Affairs direct the Under Secretary for 

Health to

• ensure that VAMCs send all required initial peer reviews (level of care 

2 and 3) to the peer review committee;

• ensure VAMCs’ peer review committees complete final peer reviews 

within 120 calendar days;

• provide clear guidance and assistance on the purpose, development, 

and implementation of peer review triggers; and

• require VAMCs to periodically provide data on peer review triggers, 

including the number of providers that have exceeded the triggers as 

part of the protected peer review data VAMCs report to VISNs on a 

quarterly basis.

To address the nonprotected FPPE process, we recommend that the 

Secretary of Veterans Affairs direct the Under Secretary for Health to 

Recommendations for 

Executive Action
 

Page 33 GAO-14-55 VA Adverse Events

develop more specific policy on the FPPE process, including 

documentation requirements such as the FPPE’s purpose, time period 

covered, evaluator’s assessment, and the summary of actions to be 

taken. 

VA provided written comments on a draft of this report, which we have 

reprinted in appendix II. In its comments, VA generally concurred with our 

conclusions and our five recommendations, and described the agency’s 

plans to implement each of our recommendations. VA also provided 

technical comments, which we have incorporated as appropriate. 

In response to our first and second recommendations that VA ensure that 

all initial peer reviews (levels of care 2 and 3) be sent to the peer review 

committee for review and that the committee’s reviews be completed 

within 120 days, VA stated that it will provide refresher education to key 

staff, such as chiefs of staff, risk managers, and VISN officials. VA 

anticipates that its planned actions will be completed by December 31, 

2013.

In response to our third recommendation that VA provide clear guidance 

and assistance on the purpose, development, and implementation of peer 

review triggers, VA stated that refresher education on this policy 

requirement, which also encompasses professional activity triggers, was 

communicated to key staff, such as chiefs of staff, risk managers, and 

VISN officials, through a conference call. Additionally, VA stated that staff 

in the VHA Risk Management Program, Office of Quality, Safety and 

Value will be available to provide consultative assistance to facilities that 

are unclear on how to implement this requirement. VA anticipates 

completion of these activities by December 31, 2013.

In response to our fourth recommendation that VA require VAMCs to 

periodically provide data on peer review triggers, VA concurred. VA 

stated that VAMCs will be required to submit a deidentified, summary 

report discussing trends and analysis of aggregate data on peer review 

activity with their quarterly submission to the VISN. VA stated that this 

new requirement will be included in the fiscal year 2014 revision of VHA 

Directive 2010-025, Peer Review for Quality Management, which 

establishes that the VAMC’s medical executive committee is responsible 

for determining peer review or professional activity trigger levels. VA 

anticipates completion of these activities by September 30, 2014. VA 

disagreed with the latter part of our recommendation that the data 

submitted should include the number of providers that have exceeded the 

Agency Comments

and Our Evaluation
 

Page 34 GAO-14-55 VA Adverse Events

triggers. VA stated that reviewing aggregate data for the number of 

providers who exceeded trigger thresholds would represent skewed data, 

which VA officials believe is not reflective of the quality of care provided 

by those providers submitted for triggered reviews. VA stated larger 

facilities may appear to have artificially higher levels of providers referred 

for detailed assessments than those of smaller facilities. We agree with 

VA that VAMC clinical leadership, with VISN oversight, input, and 

support, is the preferred means to handle trigger thresholds and data 

analysis; however, VA did not specify what data on protected peer review 

triggers that VAMCs would be required to report. We maintain that it is 

important for VAMCs and the VISNs to review whether the peer review 

triggers are implemented as intended. Part of this review should include 

monitoring how many providers have exceeded the trigger thresholds. 

Additionally, we believe that collecting and reporting such data will help 

the VISNs and VHA ensure that the protected peer review process 

contributes to organizational improvements and favorable patient 

outcomes.

In response to our fifth recommendation that VA develop more specific 

policy on the FPPE process, including documentation requirements such 

as the FPPE’s purpose, time period covered, evaluator’s assessment, 

and the summary of actions to be taken, VA stated that it will develop 

guidance on the FPPE process that will begin with a description of the 

process for a detailed assessment and define the FPPE for cause 

process if an opportunity to improve is indicated. VA further noted that the 

guidance will end with an overview of the adverse action process to be 

initiated when the provider does not demonstrate adequate improvement 

and a reduction or revocation of clinical privileges appears to be 

indicated. VA anticipates completion of these activities by September 30, 

2014. While we understand VA’s intention of expediting dissemination of 

information about the FPPE process through guidance, we believe that it 

is important for the guidance to be included in the next formal iteration of 

VHA policy.

We are sending copies of this report to the appropriate congressional 

committees, the Secretary of Veterans Affairs, the Under Secretary for 

Health, and other interested parties. In addition, the report is available at 

no charge on the GAO website at http://www.gao.gov. 
 

Page 35 GAO-14-55 VA Adverse Events

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. GAO staff who made major contributions to this report 

are listed in appendix III. 

Debra A. Draper

Director, Health Care
Appendix I: Example of a VA Medical Center’s 

(VAMC) Focused Professional Practice 

Evaluation (FPPE) Template

Page 36 GAO-14-55 VA Adverse Events

This FPPE form is a full recreation of a template used by one of the 

VAMCs we visited.

Appendix I: Example of a VA Medical 

Center’s (VAMC) Focused Professional 

Practice Evaluation (FPPE) Template
Appendix I: Example of a VA Medical Center’s 

(VAMC) Focused Professional Practice 

Evaluation (FPPE) Template

Page 37 GAO-14-55 VA Adverse Events
Appendix I: Example of a VA Medical Center’s 

(VAMC) Focused Professional Practice 

Evaluation (FPPE) Template

Page 38 GAO-14-55 VA Adverse Events
Appendix I: Example of a VA Medical Center’s 

(VAMC) Focused Professional Practice 

Evaluation (FPPE) Template

Page 39 GAO-14-55 VA Adverse Events
Appendix II: Comments from the Department 

of Veterans Affairs

Page 40 GAO-14-55 VA Adverse Events

Appendix II: Comments from the Department 

of Veterans Affairs
Appendix II: Comments from the Department 

of Veterans Affairs

Page 41 GAO-14-55 VA Adverse Events
Appendix II: Comments from the Department 

of Veterans Affairs

Page 42 GAO-14-55 VA Adverse Events
Appendix II: Comments from the Department 

of Veterans Affairs

Page 43 GAO-14-55 VA Adverse Events
Appendix II: Comments from the Department 

of Veterans Affairs

Page 44 GAO-14-55 VA Adverse Events
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 45 GAO-14-55 VA Adverse Events

Debra A. Draper, (202)512-7114 or draperd@gao.gov

In addition to the contact named above, Marcia Mann, Assistant Director; 

Ashley Dixon; Mariel Lifshitz; Katie McConnell; Elizabeth Morrison; 

Lisa Motley; Ann Tynan; and Michael Zose made key contributions to this 

report.

Appendix III: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 

(291059)
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